School breakfast programmes for adolescents · School breakfast programmes for adolescents may provide positive benefits when attended on a regular basis. Schools need to be able

School breakfast programmes for

adolescents

Literature review

Prepared for the Communities Team

by the Information Team

Community & Public Health

April 2014

The information contained in this document may be derived from a number of sources.

Although the CDHB has taken reasonable steps to ensure that the information is accurate, it

accepts no liability or responsibility for any acts or omissions, done or omitted in reliance in

whole or in part, on the information. Further, the contents of the document should be

considered in relation to the time of its publication, as new evidence may have become available

since publication. The Canterbury District Health Board accepts no responsibility for the

manner in which this information is subsequently used.

© Canterbury District Health Board, 2014.

Executive summary

Background

Regular breakfast consumption by adolescents is related to greater nutrient intake and health-

promoting behaviours; improved academic performance, cognitive function, and cardiometabolic

measures; and healthy weight maintenance.

Many New Zealand adolescents do not consume breakfast regularly; in particular females, Māori,

Pacific, and those living in more deprived areas. A variety of sociocultural, demographic,

environmental and personal factors have been identified as encouraging regular breakfast

consumption, including a supportive family and peer environment. The two most common reasons

stated for not consuming breakfast are lack of time in the morning, and not feeling hungry.

In an attempt to decrease inequities and improve health, social, and academic outcomes for

vulnerable young people by increasing access to food, the provision of free or subsidised breakfasts

within the school environment has been implemented in several countries.

Methods

To investigate the outcomes of free school breakfast provision to adolescents and the features of

the most effective programmes, a literature search was conducted to identify reports, theses and

recent peer-reviewed journal articles of reviews and interventions on this topic.

Several limitations to the literature review are acknowledged, in particular the reliance on mostly

observational (cross-sectional or longitudinal) rather than experimental data. Also, the school

breakfast programmes included in the review are highly heterogeneous, which makes it difficult to

make conclusions about the outcomes and specific characteristics of successful programmes as a

whole. In addition, most data are from the USA and United Kingdom, and the extrapolation of

findings from other countries to a New Zealand setting is challenging due to the different

educational systems and levels of food support. Finally, most studies focussed on primary school-age

students, with only a small number of studies of adolescents.

Findings

Few studies specifically investigating the effect of school breakfast programmes for adolescents

were found. Qualitative findings indicate that people involved with the programmes (e.g. school

staff and volunteers) believe the programmes are of high importance and value. The perceived

benefits included a wide range of educational, wellbeing, nutrition, social and environmental

outcomes.

Limited quantitative findings suggest improved school attendance, mathematics scores, punctuality

and psychosocial measures for adolescents attending a school breakfast programme. Improvements

tended to be more pronounced in students who attended the school breakfast programme more

often.

Breakfast programme attendance was generally poor, and a large proportion of adolescents

continued to skip breakfast even when it was provided at school. Interventions to enhance

participation by providing breakfast at no cost to all students, and changing the timing and/or

location of breakfast, showed some positive effects on uptake.

Studies indicate that a successful school breakfast programme for adolescents needs to be inclusive,

tailored, flexible, regular, and embedded within a supportive environment with full backing from

school staff and community networks. Secure funding and a stable workforce contribute to the

effective operation and long-term viability of a programme.

Conclusions

School breakfast programmes for adolescents may provide positive benefits when attended on a

regular basis. Schools need to be able to customise programmes to the needs of their students and

have access to sufficient resources to ensure a sustainable programme with high uptake.

Table of contents

Introduction ............................................................................................................................................ 1

Methodology ...................................................................................................................................... 1

Limitations of the evidence base ........................................................................................................ 2

Limitations of this review ................................................................................................................... 3

Background ............................................................................................................................................. 4

Effects of breakfast consumption by adolescents .............................................................................. 4

Breakfast consumption by adolescents in New Zealand .................................................................... 5

Determinants of breakfast consumption by adolescents .................................................................. 6

Adolescents’ barriers to consuming breakfast ................................................................................... 7

Provision of breakfast in schools ........................................................................................................ 8

Findings ................................................................................................................................................. 10

Outcomes of school breakfast programmes .................................................................................... 10

Interventions to increase adolescents’ participation in school breakfast programmes .................. 14

Components which affect the success of school breakfast programmes for adolescents .............. 15

Conclusions ........................................................................................................................................... 17

Appendix A: Evaluations of school breakfast programmes for adolescents ........................................ 19

Appendix B: School food programmes in New Zealand - a brief summary .......................................... 20

Non-government organisation and industry-funded school food programmes .............................. 20

Government-funded school food programmes ............................................................................... 22

Appendix C: Interventions to increase participation of adolescents in school breakfast programmes

.............................................................................................................................................................. 23

Appendix D: Recommendations for establishing school breakfast programmes ................................. 24

References ............................................................................................................................................ 25

1

Introduction

This paper has been prepared in response to a request from the Communities Team (Community &

Public Health), and presents the findings of a literature review of universal school breakfast

programmes for adolescents (aged ≈11-18 years). In particular, it will investigate the:

1. quantitative outcomes of school breakfast programmes (e.g. school attendance, academic

achievement, hunger, classroom behaviour),

2. qualitative outcomes of school breakfast programmes (e.g. attitudes towards the

programme, barriers to and promoters of participation), and

3. factors that contribute to the success of programmes.

The information gathered will inform the Communities Team in their work with secondary schools

that implement breakfast programmes for their students.

Methodology

A literature search to identify reviews and school breakfast programme interventions was conducted

via Medline, EMBASE, PSYCINFO, ERIC and EBM Reviews (using OVIDSP though the University of

Otago Christchurch Medical Library), from 2000-present, using a combination of the search terms:

child$ or school$ or student$ or adolescen$ or teen$, and

breakfast$, and

program$ or intervention or study or studies or trial or trials or random$ or controlled or

evaluat$ or assess$ or review.

A separate search for studies undertaken in New Zealand was also included. This was conducted

using the Kiwi Research Information Service1, with the search term: breakfast.

A broad search was also conducted using both Google Scholar and Google, and various combinations

of the search terms listed above.

Titles and abstracts of publications (articles, reports, and theses) extracted from the search

strategies above were assessed for relevance. Further, the reference lists of relevant publications

and websites of specific organisations (e.g. universities, New Zealand district health boards,

government departments, programme collaborators) were hand-searched to identify further

programmes.

Studies which specifically focused on providing breakfast to young people with chronic

undernourishment and/or associated health conditions (e.g. stunting, wasting, anaemia), or living in

1 http://nzresearch.org.nz/

2

areas of extreme poverty were not included in the literature review due to the limited applicability

to a New Zealand setting.

Brief summaries of the most relevant publications are included in the Findings section.

Limitations of the evidence base

The majority of studies assessing the impact of school breakfast programmes on academic, health,

and social outcomes were observational. The conclusions drawn from observational studies are

limited due to the lack of a suitable control group to compare outcomes to over time. Furthermore,

it may not be possible to obtain adequate baseline measures, the study timeframe may be of short

duration, and comparing breakfast programme participants to non-participants runs the risk of not

taking in to the account other potential differences between those who have breakfast at school and

those who do not (confounding).

Rigorous intervention studies are required to determine the effect of consuming breakfast (when

none was consumed before) or increasing the regularity of breakfast consumption. In saying this,

true randomised controlled trials are not necessarily a suitable way of assessing the effect of school

breakfast programmes on academic, health, and social outcomes due to both the logistical

constraints and the ethical concerns related to not providing breakfast to students who need it.

The school breakfast programmes included in the literature review are highly heterogeneous in

terms of programme design, implementation, school environment, education system, staffing,

duration, food provided, outcomes measured, cost, frequency of attendance, and participants’

socioeconomic and cultural characteristics. This heterogeneity makes it difficult to make conclusions

about the outcomes and specific characteristics of successful programmes as a whole.

Much of the information regarding school breakfast programmes is from the USA and United

Kingdom, where the provision of lunch, and sometimes breakfast, at school is commonplace. There

is less information on school breakfast programmes in countries (such as Australia and New Zealand)

where nationwide school food programmes do not exist. The extrapolation of programme findings

from other countries to a New Zealand setting can be challenging due to the different educational

systems and the provision of differing levels of food support. Therefore, the conclusions made must

be interpreted acknowledging that the programmes may not be entirely comparable with the New

Zealand situation.

Most studies assessed the effects of school breakfast programmes for primary school-age students

(≈5-10 years old), or included students from across a range of ages with no separate analyses for

younger and older students. Only a very small number of studies included adolescents exclusively. It

is possible that the design and implementation of programmes for adolescents may need to be

different from those of younger children due to differences such as school structure and increased

independence of adolescents (e.g. in terms of getting themselves to school, and food-related

attitudes and behaviours).

3

Limitations of this review

This review has been carried out in a short time frame and has accessed literature using databases

readily available to the Canterbury District Health Board. It is not, and does not claim to be,

comprehensive or systematic.

4

Background

Effects of breakfast consumption by adolescents

Many observational and some experimental studies have reported positive effects for adolescents

who eat breakfast2 regularly3 compared to those who do not. These include:

greater macro- and micronutrient intakes (in particular, calcium, fibre, iron, zinc, magnesium

and vitamins A, C and the B vitamins), particularly when cereal-based foods are eaten

(Affenito et al., 2013; Quigley, Taylor, & Scragg, 2007; Rampersaud, Pereira, Girard, Adams,

& Metzl, 2005; Ruxton & Kirk, 1997; Williams, 2007; Wilson, Parnell, Wohlers, & Shirley,

2006),

more health-promoting behaviours and positive dietary habits overall, including more

physical activity, being less likely to smoke, fewer skipped meals, lower alcohol

consumption, greater consumption of fruit, vegetables, and dairy products, lower

consumption of sugary beverages and unhealthy snacks, and being less likely to diet (Arora

et al., 2012; Cohen, Evers, Manske, Bercovitz, & Edward, 2003; Keski-Rahkonen, Kaprio,

Rissanen, Virkkunen, & Rose, 2003; Quigley, et al., 2007; Rampersaud, et al., 2005; Sjöberg,

Hallberg, Höglund, & Hulthén, 2003; Utter, Scragg, Ni Mhurchu, & Schaaf, 2007; Yang, Wang,

Hsieh, & Chen, 2006; Zullig, Ubbes, Pyle, & Valois, 2006),

better aspects of academic performance/cognitive function, more consistently for

malnourished groups (Cooper, Bandelow, & Nevill, 2011; Gajre, Fernandez, Balakrishna, &

Vazir, 2008; Grantham-McGregor, 2005; Hoyland, Dye, & Lawton, 2009; Pollitt & Mathews,

1998; Quigley, et al., 2007; Rampersaud, et al., 2005; Wesnes, Pincock, Richardson, Helm, &

Hails, 2003; Wesnes, Pincock, & Scholey, 2012; Widenhorn-Muller, Hille, Klenk, & Weiland,

2008),

better cardiometabolic measures (e.g. smaller waist circumference, lower fasting insulin,

lower total and low-density lipoprotein cholesterol, greater cardiorespiratory fitness, lower

percentage body fat) (Cuenca-García et al., 2013; Hallström et al., 2013; Smith et al., 2010),

and

more positive mood (Cooper, et al., 2011; Wesnes, et al., 2003; Widenhorn-Muller, et al.,

2008).

2 Studies use various definitions of the term “breakfast”. Some of these include: the first food/beverage(s)

consumed of the day, or food/beverage(s) consumed within a specific timeframe (e.g. 6-9am, or within the

first 2 hours of waking). In this literature review, the term “breakfast” is used to encompass all of these

definitions, unless stated explicitly.

3 Studies use various definitions of high frequency breakfast consumption. Some of these include: every day,

5-7 days per week, or a relative term such as “always” or “often”. In this literature review, the term

“regularly” is used to encompass all of these definitions related to the category of most frequent

consumption, unless stated explicitly.

5

Two recent reviews (de la Hunty, Gibson, & Ashwell, 2013; Horikawa et al., 2011) and several large

cross-sectional studies (Arora, et al., 2012; Hallström, et al., 2013; Kosti et al., 2008; Panagiotakos et

al., 2008; Sandercock, Voss, & Dye, 2010; Szajewska & Ruszczynski, 2010; Thompson-McCormick,

Thomas, Bainivualiku, Khan, & Becker, 2010; Utter, Scragg, Ni Mhurchu, et al., 2007; Utter, Scragg,

Schaaf, Fitzgerald, & Wilson, 2007; Yang, et al., 2006) report that adolescents who regularly eat

breakfast are significantly less likely to be classified as overweight or obese than those who do not

regularly eat breakfast. Some longitudinal cohort data indicate that over several years, adolescents

who do not regularly eat breakfast gain more weight than regular breakfast-eaters (Berkey, Rockett,

Gillman, Field, & Colditz, 2003; Merten, Williams, & Shriver, 2009; Niemeier, Raynor, Lloyd-

Richardson, Rogers, & Wing, 2006; Smith, et al., 2010).

However, not all studies consistently find this relationship, particularly after taking into account

confounding factors known to affect weight such as physical activity, ethnicity, and energy intake. As

these data are observational it cannot be definitively stated that skipping breakfast causes weight

gain (Quigley, et al., 2007; Rampersaud, et al., 2005). For this to be demonstrated, interventions

need to be undertaken which increase breakfast consumption in adolescents who do not regularly

eat breakfast to see whether this has positive effects on body weight over time.

Despite the limitations of using mostly observational data, given the body of evidence supporting

various positive effects for adolescents of eating breakfast, it is prudent to recommend regular

breakfast consumption for this age group.

Breakfast consumption by adolescents in New Zealand

Adolescence is a time of increased autonomy in terms of personal food choices, as well as high

nutritional need due to growth and development.

Despite the benefits of consuming breakfast regularly, breakfast consumption decreases with

increasing age during adolescence (Clinical Trials Research Unit, University of Auckland, & Synovate,

2010). Two nationwide surveys found that 81% of 10-14 year olds reported eating breakfast daily

(Ministry of Health, 2012) compared to approximately half of 15-18 year olds (University of Otago &

Ministry of Health, 2011). This decline in breakfast consumption over time may reflect the greater

control adolescents exert over their dietary patterns as they get older.

Rates of regular breakfast consumption are significantly higher for:

males, compared to females,

non-Māori and non-Pacific groups, compared to Māori and Pacific, and

those living in the least deprived areas, compared to those living in the most deprived areas

(Adolescent Health Research Group, 2003; Clark et al., 2013; Ministry of Health, 2008, 2012;

University of Otago & Ministry of Health, 2011).

These differential rates of breakfast consumption in New Zealand according to age, sex, minority

ethnic group, and level of deprivation are in accordance with numerous international data (e.g.

(Currie et al., 2008)).

6

A national survey of 3,275 New Zealand children aged 5-14 years of age revealed that the most

commonly consumed breakfast items were breakfast cereal (57%), bread/toast (35%), chocolate

flavoured drink (e.g. Milo, 14%), juice/fruit drink (11%), milk (as an unflavoured beverage, 8%),

tea/coffee (5%) and fruit (5%) (Wilson, et al., 2006). The specific breakfast choices of older New

Zealand adolescents have not been analysed in any recent surveys. However, it is reasonable to

assume that breakfast cereal and bread/toast are also commonly eaten for breakfast by this age

group.

Different ethnic groups in New Zealand may not eat a cereal- or bread-based breakfast. For example,

rice, beverages, or leftovers from the previous evening’s meal may be more commonly consumed. A

review conducted by the Scientific Committee of the Agencies for Nutrition Action included

information provided by both a dietitian and nutrition worker on Māori and Pacific breakfast habits

(Quigley, et al., 2007). This review suggested that Māori children, and Pacific children who have

grown up in New Zealand, also commonly consumed breakfast cereal and/or toast for breakfast.

Most secondary school students who reported eating breakfast source their breakfast from home

(84-97%, depending on age) (Clinical Trials Research Unit, et al., 2010). Those who do not have

breakfast at home are more likely to purchase food on the way to school (Utter, Scragg, Ni Mhurchu,

et al., 2007), and a significantly higher proportion of Pacific children eat breakfast on the way to

school compared to Māori and New Zealand European/other ethnicity children (Jamieson & Koopu,

2007; Parnell, Scragg, Wilson, Schaaf, & Fitzgerald, 2003).

Determinants of breakfast consumption by adolescents

The identification of influences on breakfast consumption is important for the development of

interventions aimed at promoting regular breakfast consumption among adolescents. The following

determinants have been found to be related significantly to breakfast-eating by adolescents, and

have been grouped into personal, sociocultural, economic and environmental factors.

Personal factors:

consuming breakfast regularly from an early age (Bruening, Larson, Story, Neumark-Sztainer,

& Hannan, 2011; Merten, et al., 2009),

positive attitude to eating breakfast (DeJong, van Lenthe, van der Horst, & Oenema, 2009;

Martens, van Assema, & Brug, 2005), and

intention to eat breakfast (DeJong, et al., 2009).

Sociocultural factors:

frequently eating meals together as a family (DeJong, et al., 2009; Utter, Scragg, Schaaf, & Ni

Mhurchu, 2008; Videon & Manning, 2003),

regular parental and sibling breakfast-eating (DeJong, et al., 2009; Keski-Rahkonen, et al.,

2003; Pearson, Biddle, & Gorely, 2009),

healthy parental eating behaviours (Hallström et al., 2011; Pearson, Williams, Crawford, &

Ball, 2012),

7

parental/family communication and supervision (Moore & Harré, 2007; Pearson, Biddle, et

al., 2009),

presence of a parent at breakfast time (Moore & Harré, 2007),

parental encouragement to eat a healthy diet (Hallström, et al., 2011),

greater family cohesion (Moore & Harré, 2007),

living in a two-parent family (Hallström, et al., 2011; Jørgensen, Pedersen, Meilstrup, &

Rasmussen, 2011; Levin, Kirby, & Currie, 2012; Pearson, Biddle, et al., 2009; Pearson,

MacFarlane, Crawford, & Biddle, 2009; Vereecken et al., 2009),

having some household guidelines/rules around breakfast (e.g. whether breakfast should be

eaten, certain foods that are/are not allowed for breakfast) (DeJong, et al., 2009; Videon &

Manning, 2003),

regular peer breakfast-eating (DeJong, et al., 2009),

peer encouragement to eat a healthy diet (Hallström, et al., 2011), and

healthy peer eating patterns (Hallström, et al., 2011; Pearson, et al., 2012).

Economic factors:

higher family socioeconomic position (Hallström, et al., 2011; Keski-Rahkonen, et al., 2003;

Merten, et al., 2009; Vereecken, et al., 2009), and

higher maternal education (Hallström et al., 2012; Hallström, et al., 2011; Pearson,

MacFarlane, et al., 2009).

Environmental factors:

having sufficient breakfast products available at home (DeJong, et al., 2009; Pearson, Biddle,

et al., 2009).

This list shows that there are many influences that impact on whether an adolescent consumes

breakfast or not, most of them related, and many beyond the control of the adolescent themselves.

Studies suggest that forming a habit of eating breakfast in early childhood and having positive

attitudes/intentions towards breakfast can encourage eating breakfast at the individual level. Wider

sociocultural factors such as a supportive and positive family and peer environment appear to

encourage breakfast eating, likely through the role modelling and normalising of regular breakfast

consumption. Unsurprisingly, living in a household with greater access to resources seems may

create an environment that is amenable to regularly eating breakfast.

Adolescents’ barriers to consuming breakfast

The two most common reasons cited by adolescents for not consuming breakfast are:

lack of time in the morning, and

not feeling hungry (Bailey-Davis et al., 2013; Community & Public Health, 2013; Shaw, 1998;

Sweeney & Horishita, 2005).

Breakfast may be viewed as non-essential, and something that can be sacrificed if young people are

short on time in the morning. This may be particularly true if breakfast is not seen as important and

8

other morning activities are prioritised (such as getting ready, and taking other siblings to school).

During adolescence the internal body clock shifts sleep timing later (Crowley, Acebo, & Carskadon,

2007), meaning that adolescents tend to wake later in the morning (resulting in less time available

for the morning routine), and may not feel hungry or ready to eat soon after getting up.

In addition, ethnicity and/or cultural practices have not been given much consideration in breakfast-

related literature. For some groups, breakfast may not be a common cultural practice, and the

influence of family tradition and routine may play a large part in determining whether young people

are offered, and eat, breakfast regularly. A small qualitative study undertaken by the New Zealand

Health Sponsorship Council (now part of the Health Promotion Agency) with Māori and Pacific

parents of school-age children identified several beliefs and behaviours related to breakfast

consumption (Murray, 2011). These included:

having heard that eating breakfast was important, but not knowing why, or not believing

that it was true,

not eating breakfast themselves,

purchasing breakfast foods based on price, rather than nutritional value,

believing that children should be responsible for making their own breakfast (from around 8-

9 years of age), and

not encouraging children to eat breakfast if they (the parent) did not think that it was

important.

Of importance to note is some of the parents stated that they were at work in the morning while

their children were getting ready for school. So even if parents thought that their children should be

eating breakfast, they were not always there to supervise this. The parents of children who ate

breakfast more often tended to believe that breakfast was important, ate breakfast themselves,

valued routine, had a focus on health, and made breakfast for their children. While this study was

small (n=23), and may not be representative of Māori and Pacific parents as a whole group, it

provides some insight into the attitudes of some individuals towards breakfast-eating.

A lack of food available in the home due to food insecurity4 may be another potential barrier to

consuming breakfast. It has been reported that in New Zealand, over 15% of households experience

food insecurity (Carter, Lanumata, Kruse, & Gorton, 2010), with females, Māori and Pacific

households, and those living in more deprived areas reporting greater food insecurity (Carter, et al.,

2010; Parnell, Reid, Wilson, McKenzie, & Russell, 2001; Russell, Parnell, & Wilson, 1999). Although

breakfast skipping tends to be more common in these groups, few studies have adequately analysed

food insecurity in households with adolescents (or other related factors such as socioeconomic

position or income) as a barrier to breakfast consumption.

Provision of breakfast in schools

In an attempt to decrease inequities and improve health, social, and academic outcomes for

vulnerable children by increasing access to food, the provision of free or subsidised breakfast within

4 Food security is a term that encompasses the ready availability of nutritionally adequate and safe foods, and the assured ability to acquire personally acceptable foods in a socially acceptable way (Russell, et al., 1999).

9

the school environment has been implemented in several countries. A great deal of resources are

invested in these programmes; it is therefore important to know whether or not they are attended

regularly and are effective.

While a very small number of randomised controlled intervention studies have assessed the

effectiveness of providing free school breakfast on various outcomes, these have been undertaken

with primary school-age children. More information is required on the outcomes of implementing

these programmes in secondary schools, as well as identifying any factors which increase their

effectiveness.

10

Findings

This section will specifically outline research related to universal school breakfast programmes (i.e.

where breakfast is offered at school free of charge to all students). In particular, it will investigate

the quantitative and qualitative outcomes of breakfast provision at school, and the factors of

implementation that contribute to the success of programmes.

Outcomes of school breakfast programmes

In some countries (such as the United Kingdom, France, Sweden, Chile, and the USA), school meals

are subsidised by the government (Harper, Wood, & Mitchell, 2008). These schools provide lunch

(and sometimes breakfast), with low-cost or free meals often available to children from low-income

households. A large body of observational research accompanies these programmes, covering a

wide range of outcomes. The collection of outcome data depends on the objectives of the

programme, and can include:

school attendance and punctuality,

cognitive performance,

academic achievement,

conduct (behaviour) at school,

physiological measures (e.g. Body Mass Index),

dietary habits and nutrient intakes,

attitudes, norms, intentions, and behaviours (e.g. related to breakfast, the school breakfast

programme, school in general),

social and emotional skills and competencies,

satiety, and

food security or household economics.

There are also outcomes for the programme itself, and these may include:

the number of students participating in the breakfast programme (in particular, those who

regularly do not eat breakfast),

programme sustainability (e.g. in terms of funding, workforce, support), and

attitudes of stakeholders towards the programme.

Keeping in mind the methodological limitations of many studies (see Introduction), reviews of school

breakfast programmes indicate significant increases in both school attendance and achievement,

with younger, more disadvantaged, and less well-nourished participants most likely to benefit (Food

Research and Action Centre, 2014a, 2014b; Grantham-McGregor, 2005; Greenhalgh, Kristjansson, &

Robinson, 2007; Hoyland, et al., 2009; Kristjansson et al., 2007; Taras, 2005). It is hypothesised that

improved achievement may be due to due to increased attendance (and therefore, time) at school,

as well as any independent effect that eating breakfast may have on cognitive performance.

11

As most studies in these reviews have been conducted with children of primary school age, the

following sections specifically look at evaluations of programmes which included providing school

breakfast to adolescents (aged ≈11-18 years). Refer to Appendix A for a brief summary of the

student-related outcomes from evaluations of school breakfast programmes described below.

USA-based school breakfast programmes for adolescents

Two studies evaluated universal free school breakfast provision in schools which previously had a

targeted approach with free, reduced and full-priced breakfast (depending on student eligibility).

Data from students 8-13 years of age from three public schools in Philadelphia and Baltimore were

collected from multiple sources: school records (n=133), student and parent interview (n=85), and

teachers (n=76) (Murphy et al., 1998). Prior to the introduction of the universal breakfast

programme, mean daily participation of all students was 15%. Students who participated in the

programme sometimes or often had significantly better school-recorded mathematics test scores,

student-reported depression and anxiety scores, parent-reported psychosocial symptoms, and

teacher-reported hyperactivity index scores than children who rarely participated in the programme.

There was no significant effect of school breakfast programme participation on school absence or

lateness, or science, social studies or reading grades.

Four months after the introduction of the universal programme, mean daily participation increased

significantly to 27%. Students who participated in the universal programme sometimes or often

were absent or late to school significantly less often, and had significantly better mathematics test

scores, and hyperactivity index scores than students who rarely participated. There was no

significant effect of programme participation on student-reported depression and anxiety scores, or

parent-reported psychosocial symptoms.

Those students who increased their participation in the programme over the 4 months were

significantly more likely to decrease their rate of school absence, and increase their punctuality,

mathematics test scores, student-reported depression and anxiety scores, parent-reported

psychosocial symptoms, and hyperactivity index scores than students whose level of participation

stayed the same or decreased.

Both cross-sectional and longitudinal data from this study provide evidence that higher rates of

school breakfast programme participation were associated with improved attendance, punctuality

and student academic and psychosocial functioning in the short-term.

In addition to this, a longitudinal study of 97 students 9-11 years of age was conducted in three

schools in Boston (Kleinman et al., 2002). Prior to the implementation of the universal programme,

students who ate school breakfast rarely were significantly more likely (41%) to be “nutritionally at

risk” than were children who ate school breakfast sometimes (7%) or often (17%). This was defined

as consuming two or more nutrients at ≤50% of the recommended daily allowance and/or having an

energy intake ≤50% of the recommended daily allowance.

Six months after the introduction of the universal programme, the nutrient intake of 19% of

students had improved, while the nutrient intake of 64% of students had not changed, and the

nutrient intake of 18% of students had worsened. Students whose nutritional intake had improved

12

had significantly larger increases in school breakfast participation than children whose nutrient

intake had stayed the same or worsened. Improvements in nutrient intake were associated with

significant improvements in school attendance, mathematics grades, child-reported psychosocial

functioning, and decreases in food insufficiency. However, since these outcomes were not

specifically analysed in relation to school breakfast consumption, it is not possible to say whether

programme participation was causally related to these improvements.

Europe-based school breakfast programmes for adolescents

A controlled pilot study was conducted to evaluate whether breakfast served in a secondary school

in Norway could improve the dietary habits and school performance of students (Ask, Hernes, Aarek,

Johannessen, & Haugen, 2006). Fifteen year-old students in one class were offered a free breakfast

at the beginning of each school day for 4 months (n=26), while students in a second class were not

(and acted as a control group, n=28). Both classes received education on the importance of healthy

eating. All students completed two questionnaires - one on school factors (environment, own

performance, and satisfaction) and one short non-validated food frequency questionnaire, four

weeks before the study started and one week after the study ended. Body weight and height were

measured by the school nurse at the beginning and end of the study.

Almost all students in the intervention group had breakfast at school every day during the

intervention. There was no significant change in Body Mass Index between the beginning and end of

the study for the intervention group; however, it did increase significantly for the control group

(both males and females). There was no significant effect of school breakfast on the amount of time

spent doing homework, or student-rated school environment. Males in the intervention group (but

not females) reported significantly improved dietary habits (as measured by a healthy eating index),

and an increase in school contentment. In the control group, the frequency of eating lunch increased

significantly. One week after the study ended the students in the intervention group had returned to

their usual breakfast pattern.

Reports from a small number of teachers suggest that the school attendance and social behaviour of

students receiving school breakfast improved. However, some teachers were not happy with certain

practical aspects of the breakfast, as it delayed the first class of the day.

The findings from this small pilot study suggest that a school breakfast programme may contribute

to weight maintenance. However, the small sample size limits the robustness of the findings.

Australia-based school breakfast programmes for adolescents

There are several school breakfast programmes running in Australia, including the Good Start

Breakfast Club5 (operated by the Australian Red Cross), and the School Breakfast Program6 (operated

by Foodbank WA).

5 http://www.redcross.org.au/good-start-breakfast-club.aspx

6 http://www.healthyfoodforall.com.au/school-breakfast-program/

13

The School Breakfast Program commenced in 2001 and currently works with over 425 schools in

Western Australia. The Australian Government and corporate sponsors provide funding to Foodbank

WA to purchase and transport the breakfast products (including wheat biscuits, oats, fruit, canned

spaghetti and baked beans, bread, Vegemite, milk and yoghurt) to schools. An evaluation of the

programme was conducted in 2011, which surveyed the programme coordinator or school principal

of 271 participating primary and secondary schools (Davies, 2012). The majority of respondents

agreed that the breakfast programme positively influenced a wide range of educational, wellbeing,

nutrition, social and environmental outcomes. These outcomes included school attendance, student

behaviour and concentration, student physical and mental health, and the health-promoting

environment of the school.

Two case studies of secondary schools in Western Australia that participated in the School Breakfast

Program were also conducted (TNS Social Research, 2010).

The first was at a remote district school in an area of high socioeconomic disadvantage (school roll

≈360 students, aged from ≈5-18 years). Breakfast was provided in the classroom prior to school

start, and adolescent students prepared their own breakfast and cleaned up afterwards. At first,

breakfast was only offered to students who had not had breakfast; however participation was low

due to the stigma of being singled out. Participation in the programme increased considerably when

a universal programme was implemented. The second case study was at a regional district school

(school roll size not stated, students aged from ≈5-16 years). Eight to 25 students attended breakfast

at school each day, and it was estimated that around half of the students attended at some point,

with different students attending on different days.

Although the School Breakfast Programs were not the only initiative undertaken to improve

outcomes for students over a period of a few years, school staff and parents all agreed that the

programmes were successful and contributed to a wide range of benefits. It was proposed that the

programme played a role in improved school attendance, student and parent engagement with

school, student behaviour, and broader life skills and behaviours (including food preparation,

understanding of healthy eating, sense of responsibility and respect, basic hygiene, interacting with

adults, and sociability). It was also felt that the programme ensured a stable source of food,

increased access to healthy food, and created the opportunity to try new or different foods. Some

interviewees mentioned that the programme provided a secure place for students to go in the

morning, a caring atmosphere, and a place to transition between the home and school environment.

They also felt that breakfast time provided an opportunity to build relationships between students

and teachers outside of the classroom.

New Zealand-based school breakfast programmes for adolescents

Despite particular consideration given to sourcing New Zealand-specific research, no studies of

school breakfast programmes for New Zealand adolescents that reported student outcomes were

found. There is a small number of school food programmes in New Zealand, which are supported

variously by school, community, non-government organisation, industry or government funding.

Many programmes target low decile and/or primary schools; however some secondary schools do

14

operate programmes for students, including breakfast programmes. Refer to Appendix B for a brief

summary of school food programmes in New Zealand.

Summary of outcomes from school breakfast programmes for adolescents

Few studies specifically investigating the effect of school breakfast programmes for adolescents

were found. The programmes included in this review differ in their format, setting, menu, staff and

implementation, highlighting the ability to tailor programmes to an individual school’s needs.

Differences exist not only between countries, but also between schools and/or programmes within

the same country. Despite international research existing on school breakfast programmes, it is

difficult to extrapolate these findings to a New Zealand setting where school systems and school

food provision differ greatly.

Qualitative findings indicate that people involved with the programmes (e.g. coordinators, school

staff, parents and volunteers) believe the programmes are of high importance and value. The

benefits mentioned included a wide range of educational, wellbeing, nutrition, social and

environmental outcomes.

Quantitative findings suggest improved school attendance, mathematics scores, punctuality and

psychosocial measures for those students attending a school breakfast programme. More limited

evidence suggests improved nutrient intake, dietary habits, and weight maintenance. Improvements

tended to be more pronounced in students who attended the school breakfast programme more

often.

Interventions to increase adolescents’ participation in school breakfast

programmes

As described in the previous section, school breakfast programme attendance is generally poor, and

a large proportion of adolescents continue to skip breakfast even when it is provided at school at

low or no cost. Some of the barriers cited by adolescents and their parents/caregivers for not

participating in a school breakfast programme include:

lack of time in the morning (e.g. having to arrive at school early enough to eat breakfast

before school starts, or problems with bus/transport timetables),

social stigma associated with participation in a programme aimed at youth from low-income

families,

unmet food needs (e.g. dislike of the foods offered, little variety, lack of culturally

appropriate foods, perceived poor food quality),

other breakfast consumption practices (e.g. students purchase food and/or beverages from

food outlets on the way to school - with or without parent/caregiver knowledge),

cost (in schools where school breakfast provision is not universal),

not feeling hungry, and

fear of becoming overweight (Bailey-Davis, et al., 2013; Basch, 2011; Mollie Greves et al.,

2007; Olsta, 2013; Reddan, Wahlstrom, & Reicks, 2002; Sabol, Struempler, & Zizza, 2011).

15

To try to increase the uptake of school breakfast programmes by adolescents, several interventions

which aim to address some of the barriers to participation have been studied. Interventions to

enhance school breakfast programme participation usually focussed on two types of strategies:

providing breakfast at no cost (i.e. universal provision), and/or

changing the environment in which breakfast was provided.

Universal school breakfast programmes can significantly increase participation rates (Food Research

and Action Centre, 2014a, 2014b; Leos-Urbel, Schwartz, Weinstein, & Corcoran, 2013; Murphy, et

al., 1998), and may influence uptake in multiple ways. Most obviously, it means that those who

cannot otherwise participate due to the monetary cost are able to do so. Also, universal

programmes may counteract some of the stigma, as breakfast is free and available for all students,

not just those from low-income families.

Breakfast (unlike morning tea and lunch) is not incorporated into the school day, and students must

arrive early in order to participate. By changing school policies and practices regarding the timing

and location of breakfast provision, a more flexible and less formal eating environment is created

meaning more students may attend. Novel environmental approaches such as offering “grab-and-

go” breakfast options, allowing students to consume breakfast in the classroom in the morning (as

opposed to before school), and/or providing breakfast in the mid-morning break, have been found

to be acceptable and feasible ways to increase participation (Food Research and Action Centre,

2014a, 2014b; Morris, Courtney, Bryant, & McDermott, 2010; Nanney, Olaleye, Wang, Motyka, &

Klund-Schubert, 2011; Olsta, 2013).

Refer to Appendix C for a brief summary of the interventions described above that aimed to increase

participation of adolescents in school breakfast programmes.

Components which affect the success of school breakfast programmes for

adolescents

To implement an effective school breakfast programme, it is necessary to identify any factors which

may enhance their design and/or implementation. Few studies of the school breakfast programmes

for adolescents mentioned previously reported on any contextual elements that may have

influenced outcomes, or the use of process evaluation methods for this purpose. Factors that could

impact on programme effectiveness were identified from qualitative descriptions, and some general

features of programmes which showed positive outcomes.

Factors that were thought to lead to greater student participation and improved student outcomes

included:

using a universal approach, where breakfast is available to all students at no cost,

developing the programme with the needs of the students in mind, incorporating their input

in the design and delivery, to create a strong sense of ownership,

having the programme embedded in the school system,

being flexible with the time and location of breakfast provision,

holding the programme in an appropriate location on school premises, and

16

running the programme on a frequent and long-term basis.

As well as identifying components of a programme which may improve its success, it is also

important to consider any factors that may limit its operation and future viability. Some of the

barriers to implementing school breakfast programmes for adolescents included:

set-up and ongoing costs (e.g. limiting the ability to extend the programme to all days of the

week),

social stigma associated with a programme that may be perceived to be aimed solely at

students from low-income families, and

negative or unsupportive views of school personnel and the wider community, such as those

related to additional workload, cost, mess, and the creation of “dependency”.

Some potential risks to the long-term sustainability of programmes were also identified. These were:

funding shortfalls (which is particularly pertinent to the many programmes which rely

exclusively on donations of money and/or foodstuffs),

high staff and/or volunteer turnover, and relatedly

reliance on a single person or a group of volunteers to co-ordinate and run the programme.

These factors suggest that a successful school breakfast programme for adolescents needs to be

inclusive, tailored, flexible, regular, and embedded within a supportive environment with full backing

from school staff and community networks. Secure funding and a stable workforce, for example

having a paid programme coordinator (rather than relying entirely on teachers and volunteers), and

splitting the organisational duties between a number of people with clear roles and responsibilities

can contribute to the effective operation and continuation of a programme.

Several organisations have published recommendations for establishing school breakfast

programmes which incorporate many of these features. Refer to Appendix D for a list of some of

these guidelines from various countries.

17

Conclusions

Despite the benefits of eating breakfast, many New Zealand adolescents do not consume breakfast

regularly. This is most common for females, Māori, Pacific, and those living in more deprived areas.

Several countries (including New Zealand) have attempted to address these inequities and improve

health, social, and academic outcomes for vulnerable young people by increasing access to food

through free school breakfast programmes.

Despite the intention of many school breakfast programmes to reduce inequities and provide food

to students in need, few studies have actually assessed programme outcomes in relation to

socioeconomic position, food security or ethnicity adequately. School breakfast programmes could

potentially reduce the risk of household food insecurity in multiple ways (Bartfeld & Ahn, 2011;

Bowers et al., 2009; Walton, Signal, & Thomson, 2009). For example, providing food directly to

students may relieve some pressure on the household food budget and mean that finances can be

redistributed, or the uncertainty and anxiety around the availability of sufficient food could be

reduced.

In the current literature review, few studies specifically investigating the effect of school breakfast

programmes for adolescents were sourced. Those that were found were highly heterogeneous, also

included younger children, and were based overseas, limiting extrapolation to school breakfast

programmes in New Zealand secondary schools. These studies suggest that those people involved

with the programmes believe them to be of high importance and value, and that the programmes

contribute to a wide range of educational, wellbeing, nutrition, social and environmental benefits.

When considered in addition to reviews and randomised controlled trials of school breakfast

programmes including mostly primary school-age children, studies which include adolescents

support evidence that frequent participation may increase school attendance, achievement,

punctuality, satiety and psychosocial outcomes.

It is important to remember that school breakfast programmes are not just vehicles to provide food

to children of low income families. They also provide a unique opportunity for learning and

interaction as all adolescents can benefit from the increased opportunities to practice healthful

behaviours, make positive food choices, engage socially, and take leadership roles. These practical

skills and behaviours can extend beyond school to the broader family and community context.

Although many studies discussed the potential for school breakfast programmes to impact on wider

benefits such as social skills, health-promoting behaviours, and attitudes, few assessed these less

tangible but important outcomes.

Participation of adolescents in school breakfast programmes was generally poor, and the majority of

students continued to skip breakfast even when it was provided at school. Higher participation rates

were observed when breakfast was offered at no cost to all students, and policies and practices

regarding the timing and/or location of breakfast were adapted. This highlights the benefit of

individual schools being able to customise a flexible programme to meet the specific needs of its

18

student population. Special consideration needs to be given to encourage adolescents who skip

breakfast regularly to participate in school breakfast programmes.

Findings indicate that a successful school breakfast programme for adolescents needs to be

inclusive, tailored, regular, and embedded within a supportive environment with full backing from

school staff and community networks. For example, when a programme is incorporated into the

whole school environment it becomes part of the usual school day, and practices can be aligned with

the health curriculum and other nutrition messages. Also involving students, school food service

personnel, and community stakeholders in the design and implementation of the programme can

ensure its relevance and appeal. Secure funding and a stable workforce was reported to contribute

to the effective operation and long-term viability of a programme. This point is of particular

relevance given that most school food programmes in New Zealand rely heavily on donations and

volunteer personnel.

19

Appendix A: Evaluations of school breakfast programmes for adolescents

Table 1. Summary of findings from evaluations of school breakfast programmes for adolescents

Reference Participant age (years)

n Location Programme description Outcomes

(Ask, et al., 2006)

15 26, 28a

Norway Students in one class offered free breakfast (and an optional dietary supplement) at the beginning of each school day for 4 months. Another class was not offered breakfast and acted as a control group.

High compliance. Significant improvement in eating patterns and school contentment (males only) compared to control group. Significantly lower food intake at lunch compared to control group. Breakfast habits returned to pre-intervention levels 1 week post-intervention. No significant effect on self-reported school performance and environment, and teacher-rated attention and social behaviour compared to control group. No significant change in Body Mass Index between the beginning and end of the study for the intervention group; however, it did increase significantly for the control group.

(Kleinman, et al., 2002)

9-11 97b USA Universal free school breakfast programme introduced in three schools (where free school breakfast provision was not previously universal). Outcomes assessed after 6 months.

Students whose nutritional risk decreased (i.e. who had improved nutrient intake) had significantly larger increases in school breakfast participation than children whose nutritional risk stayed the same or worsened.

(Murphy, et al., 1998)

≈8-13 163b USA Universal free school breakfast programme introduced in three schools (which previously had free, reduced or full price breakfast provision, depending on eligibility). Outcomes assessed after 4 months.

Participation increased significantly from 15% to 27%. Rate of children who rarely ate breakfast declined from 62% to 43%. Higher rates of participation in the school breakfast programme was associated with significantly improved attendance, punctuality, psychosocial measures and mathematics grades in the short-term.

a Number of participants recruited in the intervention (breakfast) group, and control group. b Number of participants assessed.

USA, United States of America.

20

Appendix B: School food programmes in New Zealand - a brief

summary

Two recent surveys have investigated the prevalence and characteristics of school food programmes

in New Zealand.

The most recent survey, of 458 school principals, board members and other school staff conducted

by the New Zealand School Trustees Association7 found that 60% of schools had access to a formal

school or community food programme (New Zealand School Trustees Association, 2013). In addition,

most schools (90%) stated that they provided food for students on an informal basis, when needed.

Lower decile schools were more likely to have a food programme, and school breakfast programmes

were the most common (60%) type.

The Child Poverty Action Group conducted a telephone survey of 17 primary, intermediate and

secondary schools in the Auckland region in 2010, which produced some similar findings (Child

Poverty Action Group, 2011). All schools (except one) provided some form of food support to

students. Breakfast was the most common form of food provision, and a significant amount of the

food was donated through formal programmes and/or donated by local businesses. Some schools

stated that they did not operate formal school food programmes, but provided food on an informal

or “ad-hoc” basis to particular students who arrived at school not having had breakfast and/or

without bringing lunch.

Non-government organisation and industry-funded school food

programmes

One example of a current school food programme operated by a non-government organisation

(KidsCan) is Food for Kids8. Food is provided directly to schools, and distributed by school staff to

children in need of assistance (KidsCan, 2011). Food for Kids is intended to be an emergency food

programme for children, supplying one meal per child per day.

In May 2007, the New Zealand Red Cross launched its nationwide Breakfast in Schools programme. It

was a community service delivery programme that offered breakfast every day to participating

decile 1 primary schools. Foodstuffs were supplied by local supermarkets (including cereal, milk,

bread, and spreads), and Red Cross covered the implementation of the programme (planning,

resources and volunteers) in conjunction with the school. In total, 59 schools were involved. An

evaluation was conducted with 12 schools after the first year of implementation (New Zealand Red

Cross, 2008). Most school staff thought that the programme had positive effects on students’ social

behaviour and learning capacity, and supported the programme. Some children (16% of the 141

7 http://www.nzsta.org.nz/home/

8 http://www.kidscan.org.nz/our-work/food-for-kids

21

surveyed) reported that they had eaten some food/beverage in the morning prior to attending the

breakfast programme, indicating some “topping up” of breakfast eaten at home. Maintaining a

volunteer workforce was identified as a challenge for schools. In May 2011, the Countdown

supermarket brand announced that it would withdraw sponsorship from Breakfast in Schools, and

the programme has since ended.

An industry-funded programme - Milk for Schools9 - started nationwide roll-out in 2013, which

provides a serving of milk every day to students of participating primary schools (irrespective of

decile).

Randomised controlled trial to assess the effectiveness of school breakfast programmes in

North Island primary schools

The effectiveness of a school breakfast programme in decile 1-4 New Zealand schools on children’s

school attendance was assessed using a stepped-wedge, cluster randomised controlled trial (Ni

Mhurchu et al., 2013; Ni Mhurchu et al., 2010). Fourteen primary schools were involved, and the

trial took place over one school year. The mean age of participants (n= 424) was 9.4 years (range, 5-

13), and 42% of were Pacific, 34% were Māori, and the remaining 23% were New Zealand European

or other ethnicities. Participation in the programme was voluntary, and breakfast was available to

students 5 days per week. Schools received either the Red Cross Breakfast in Schools programme

(consisting of Weet-Bix, low-fat milk, bread, spreads, Milo, milk powder and sugar), or one provided

by private sector industry partners (consisting of Weet-Bix and low-fat milk).

There was no statistically significant effect of the breakfast programme on children's school

attendance. There was a significant decrease in children's self-reported short-term hunger during

the intervention phase compared with the control phase. There were no effects of the intervention

on any other outcome (academic achievement, self-reported grades and sense of belonging at

school, teacher-rated behaviour, parent-reported child breakfast habits and food security). Results

indicated infrequent breakfast programme attendance. When analyses were conducted with

participants who attended breakfast ≥50% of the time, school attendance was significantly greater

during the intervention phase compared with the control phase. There was no change in the

proportion of children who ate breakfast everyday, and results suggest that those who previously

ate breakfast at home replaced this with breakfast at school. Overall, the free school breakfast

programme did not have a significant effect on children's school attendance or academic

achievement but had significant positive effects on children's short-term satiety ratings.

This study supports the findings of one other randomised controlled trial of a school breakfast

programme for primary school children in Wales (Moore et al., 2007; Murphy et al., 2011; Tapper,

Murphy, Moore, Lynch, & Clark, 2007). Both studies suggest that more frequent programme

attendance may be required to influence school attendance and academic achievement. They also

highlight that there still remains a group of children who do not consume breakfast, even when is it

provided at school free of charge.

9 https://www.fonterramilkforschools.com/about

22

Qualitative study of the features of breakfast programmes in Waikato secondary schools

A small qualitative study of breakfast programmes in four Waikato secondary schools was

undertaken in early 2009, which gathered information from school principals, breakfast programme

organisers, and students (Waikato District Health Board, 2010). Each school implemented their

breakfast programme individually, and catered to 15-30 students per session. The need for a

breakfast programme within each school was identified using informal discussion with staff and

students and/or formal survey approaches.

Schools derived funding for the programme from a variety of sources, including financial

contributions from community organisations or within the school, fundraising, donations from

students using the programme, and nationwide school breakfast programme providers. Breakfast

foods were mostly donated by businesses or purchased using programme funds. Many of the

funding and food sources were not long-term, which was identified as being an ongoing challenge

for the programmes.

Breakfast programmes were promoted using school newsletters, morning notices, posters,

assemblies and word of mouth. Views regarding promotion were mixed – promotion was not a

priority for some schools as they did not want to draw attention to the students attending, whereas

some felt that promotion helped to support participation and to overcome the possible stigma of

attendance.

The programmes were staffed by a variety of volunteers – parents, school staff, senior students, and

community members. Schools noted that it was challenging to find sufficient volunteers, however

volunteers were motivated by seeing the benefits of the programme, and being able to interact with

students in a positive setting. The value students can bring to the process, and the development of

wider skills and experience, were recognised in breakfast programmes which included leadership by

senior students.

Government-funded school food programmes

Aside from the free milk provided daily to schools between 1937 and 1967 (Ministry for Culture and

Heritage, updated 15 Nov 2013), and more recently, Fruit in Schools (Ministry of Health, 2006), New

Zealand does not have an extensive history of providing government-funded food to school

students.

In 2009, the KickStart Breakfast programme was introduced by industry partners who supplied

breakfast products (milk and Weet-Bix) on two mornings per week to participating decile 1-4

schools. Breakfast was provided to any student at no cost, and each school provided a suitable

location, serveware and personnel to implement the breakfast programme. In May 2013 it was

announced that the programme would receive government funding (up to $9.5 million over 5 years)

to gradually extend the programme to 5 days a week, and to any school that wished to participate

(irrespective of decile rating) from the beginning of 2014 (New Zealand Government, 2013). As of

January 2014, there were 630 primary and secondary schools registered to take part in the KickStart

Breakfast programme (KickStart Breakfast, 2014).

23

Appendix C: Interventions to increase participation of adolescents in school breakfast programmes

Table 2. Summary of findings from interventions to increase participation of adolescents in school breakfast programmes

Reference Participant age (years)

n Location Programme description Outcomes

(Leos-Urbel, et al., 2013)

≈8-13 ≈723,843 USA In one city, universal free school breakfast programme introduced (where previously there was a cost of 5-25c per breakfast for some, depending on eligibility). The price of lunch was increased for those ineligible for meal subsidies (from $1.00 to $1.50) to cover the cost of universal free school breakfast.

Breakfast programme participation increased (by ≈6 additional days per student per year). However, programme participation was still low overall. No significant effect on school attendance, mathematics scores or reading scores.

(Morris, et al., 2010)

9-13 Not reported

USA In one school, students offered “grab-and-go” bags of breakfast items at no or low cost (depending on eligibility) for 2 weeks.

49% of students who rarely ate breakfast participated in the programme. High acceptability from students and teachers. Concern from school principal regarding mess.

(Nanney, et al., 2011)

≈11-12 239 USA In one school, a “grab-and-go” cafeteria breakfast menu, hallway delivery service, and in-classroom eating strategies were implemented for 6 weeks in addition to the usual cafeteria breakfast. Breakfast was offered at no or low cost (depending on eligibility).

64% of students were very satisfied with eating in the classrooms. All teachers (n=10) rated eating in the classroom as not messy or disruptive, and student behaviour as excellent or good. Breakfast participation increased significantly from 0.74 to 1.21 days per student per week. Improvements were more pronounced among students eligible for free and reduced-price school meals.

(Olsta, 2013) ≈14-17 2,560 USA In one school, breakfast was made available to students (both cafeteria and mobile food cart) during morning study period after school had started, until 10:30am. Breakfast was offered at no or low cost (depending on eligibility).

Average number of daily school breakfasts increased from 80 (prior to the intervention) to 368 (18 months later).

n, number of students to whom the school breakfast programme was made available.

USA, United States of America.

24

Appendix D: Recommendations for establishing school breakfast

programmes

Several organisations have published recommendations for establishing and evaluating school

breakfast programmes. These include guidelines from:

New Zealand (Counties Manukau District Health Board, 2008; Office of the Children's

Commissioner, 2014),

Australia (Department of Education and Early Childhood Development, 2008; Foodbank WA,

2011),

The United Kingdom (New Policy Institute),

Scotland (Scottish Community Diet Project, 2004),

Ireland (Health Promotion Agency for Northern Ireland), and

Wales (Department for Children Education Lifelong Learning and Skills, 2008).

25

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